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Monday, February 1, 2010
Improving Communication in the ICU about End-of-Life Care in the ICU Reduces Symptoms of Stress, Anxiety, and Depression in Family Members
An intervention to improve communication between clinicians in the Intensive Care Unit (ICU) and family members of a dying patient significantly reduces feelings of stress, anxiety, and depression in the family members, according to a study that appears in the February 1, 2007 issue of the New England Journal of Medicine. The study, funded in part by the National Institute of Nursing Research (NINR), a component of the National Institutes of Health (NIH), showed that this intervention also allows family members to express their emotions and arrive at a more realistic expectation of the outcome.
The researchers evaluated a set of communication guidelines for family conferences between ICU clinicians and family members. Based on earlier, extensive end-of-life research conducted by one of the collaborating researchers, Dr. J. Randall Curtis of the University of Washington, and funded by NINR, the guidelines followed the mnemonic VALUE: to Value what the family members said, Acknowledge their emotions, Listen, Understand the patient as a person through asking questions, and Elicit questions from the family members.
“Communication in these difficult situations is vital to all involved, including the patients, the family members, and the ICU physicians and nurses,” said Dr. Patricia Grady, the Director of NINR. “This research furthers our understanding of how clinicians can work with family members in the decision-making process and help them cope with the impending loss of a critically ill loved one.”
“I think this is a remarkable moment in end-of-life care,” said Dr. Curtis, “because [this study] shows that improving communication about end-of-life care in the ICU results in a dramatic reduction in symptoms” related to post-traumatic stress disorder in family members up to 3 months later.
Families of a patient near death in the ICU are often under great stress, and they rely on clinicians for information and support. A family conference, bringing together the family and the involved clinicians in a quiet room to discuss the patient’s prognosis and care options, can be an important component of communication. However, the structure and conduct of these conferences has not previously been evaluated.
The study involved the family members of 126 critically ill patients cared for in 22 ICUs. When an ICU physician believed that the death of the patient was likely within a few days, a proactive family conference was called, with the aim of deciding whether life-sustaining measures such as mechanical ventilation should be continued or withdrawn. In half of these cases, the family conference proceeded under the customary ICU practice. In the other half, the physicians conducted the conferences in accordance with the VALUE guidelines. They also provided the families with a brochure on bereavement.
The ICU patients ranged in age from 56 to 80 years, most were male, and they were admitted to the ICU for respiratory, cardiac, or renal failure; coma; or shock. The involved family members averaged 54 years of age, most were female, over 60 percent were Catholic, and over 80 percent were either the spouse or the child of the patient.
On average, the customary-practice conferences involved two family members and lasted 20 minutes, with the family speaking roughly five minutes; the intervention conferences involved three family members and lasted 30 minutes, with the family speaking for over 13 minutes. While all conferences were led by the attending ICU physician, the patient’s nurse was also present in 60 percent of the customary-practice conferences and 81 percent of the intervention conferences. All conferences resulted in a decision to forgo further life-sustaining treatment.
After the conference, 95 percent of family members in the intervention group reported they had been able to express their emotions to the ICU clinicians, as compared to 75 percent of family members in the customary-practice group. In addition, among family members who initially disagreed with the decision to forgo life-sustaining treatments, those in the intervention group were more likely to concur with the decision at a later time.
“Since 1997, NINR has been the lead institute at NIH for end-of-life research. We will continue to investigate this area of science that eventually affects every one of us,” Dr. Grady noted. “Findings from this study will help inform clinicians world-wide who are involved with critically ill patients and their families.”
This project was led by Dr. Alexandre Lautrette of the Hopitaux de Paris, France. Other collaborators include Dr. Michael Darmon, Dr. Sylvie Chevret, Dr. Fabienne Fieux, Dr. Nancy Kentish Barnes, Dr. Frederic Pochard, Dr. Benoit Schlemmer, and Dr. Elie Azoulay, of the Hopitaux de Paris; Dr. Bruno Megarbane of Lariboisiere Hospital; Dr. Cedrid Bruel of Bichat-Claude Bernard Hospital; Dr. Gerald Choukroun, of Cochin Hosptial and Paris 5 Rene Descartes University; Dr. Luc Marie Joly of Rouen University Hosptial; Dr. Cristophe Adrie of Saint-Denis Hospital; Dr. Didier Barnoud of University Hospital, Grenoble; Dr. Gerard Bleichner of Argenteuil Hospital; Dr. Richard Galliot of Pontoise Hospital; Dr. Maite Garrouste-Orgeas of Saint-Joseph Hospital; Dr. Hugues Georges of Tourcoing Hospital; Dr. Dany Goldgran-Toledano of Gonesse Hospital; Dr. Merce Jourdain of Salengro Hospital; Dr. George Loubert of Raymond Pointcare Hosptial, University of Versailles; Dr. Jean Reignier of La Roche sur Yon Hospital; Dr. Faycal Saidi of Nemours Hospital; Dr. Bertrand Souweine of Clermont-Ferrand Hospital; and Dr. Francois Vincent of Avicenne Hospital. In addition to NINR, this research was funded by Assistance Publique-Hopitaux de Paris and the French Society for Critical Care Medicine.
The primary mission of the NINR, one of 27 Institutes and Centers at the National Institutes of Health, is to support clinical and basic research and establish a scientific basis for the care of individuals across the life span. For additional information, visit the NINR web site at http://ninr.nih.gov.
About the National Institutes of Health (NIH): NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.
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Lautrette, A., et al. (2007). A communication strategy and brochure for relatives of patients dying in the ICU. The New England Journal of Medicine, 356:469-478.